Westgate Hills Rehabilitation And Nursing Ctr
2050 Old West Chester Pike, Havertown, PA 19083 · For profit - Limited Liability company · 110 certified beds · (610) 449-8600 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2023
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $49,590 in federal fines (most recent 2024-01-22)
- its payroll-based staffing rating is low (2/5)
- about 20% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.6% | 16.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.5% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.2% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 20.7% | 10.8% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.6% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.2% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.4% | 20.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.0% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 20.8% | 25.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.5% | 17.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 59.5% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.8% | 22.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.4% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.67 | 1.62 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.03 | 1.18 | 1.80 | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
49.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 139 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 65.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 128 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.45 therapist hours per resident per day in 2026Q1 — more than 76% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 49.7%CMS range 41.6–57.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 14.2%CMS range 11.3–18.0 | 10.7% | Oct 2022–Sep 2024 | worse than U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 65.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 64.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 58.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 96.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.9%CMS range 4.7–10.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 110 beds and averages 102.6 residents a day — about 93% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.32 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.06 hrs/resident/day on weekends vs 3.42 on weekdays — 11% thinner on weekends. RN hours go from 0.52 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
19 citations, most serious first. The 11 most serious are shown; the remaining 8 are one tap away and print in full.
- Immediate jeopardy · K2023-12-14 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, facility policy and clinical record review, and interview with staff, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases which resulted in an Immediate Jeopardy for 60 residents on the second floor nursing unit. Findings include: Review of facility policy titled COVID-19 Prevention, Response and Reporting with a revision date of December 7, 2023, revealed It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections. Review of facility documentation revealed the facility experienced a COVID-19 outbreak beginning on December 7, 2023, and continues as of December 15, 2023, located on the second floor effecting 60 residents. Interview conducted on December 11, 2023 at 9:30 a.m. with the Director of Nursing (DON) and Acting IP…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-01-14 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews, it was determined that the facility failed to properly store food and maintain sanitary conditions and failed to properly label and date food products in the Main Kitchen which created the potential for cross contaminationFindings include: During an observation of the main kitchen on January 11, 2025, at 9:10 a.m. the following was observed: - Dry Storage: three packets of crackers on the floor, one maple syrup container on the floor, one used rubber glove on the floor, one open bag of pasta which also lacked proper dating and labeling, and one box containing 24 Glucerna Shakes on the floor -Walk in freezer- one open bag of chicken patties that was not sealed and missing appropriate date and label -Walk-in refrigerator- two open bags of bread missing a used by date and label -Prep refrigerator- one bag of sliced cheese missing appropriate date and label. Interview conducted with the Kitchen Manager on January 11, 2026, at 9:40 a.m. confirmed that all open bags and containers should have been properly sealed and contain a used by date and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-14 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records, observations, and staff interviews, it was determined that the facility failed to protect the residents' rights for two of 32 residents reviewed (Resident R31 and R43). Findings include: Resident R31 was admitted to the facility on [DATE], with the following diagnosis: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke and complete paralysis of right side), muscle wasting and atrophy, not elsewhere classified, multiple sites, and difficulty in walking, not elsewhere classified. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R31, dated December 25, 2025, revealed that the resident required supervision or touching assistance for upper body dressing and substantial/maximal assistance for lower body dressing. An interview conducted with Resident R31 on January 11, 2025, at 10:23 a.m. revealed Resident R32 was waiting on staff assistance to change out of her hospital gown…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-14 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical records review and staff interviews, it was determined that the facility failed to follow physician orders regarding administration of nutrition for one of three residents reviewed (Resident 11). Findings include: Review of Resident 11's diagnosis list revealed, nutritional deficiency unspecified (inadequate supply of essential nutrients in the diet which can lead to malnutrition or disease) and huntington's disease (inherited genetic condition that causes the general breakdown of nerve cells in the brain). Review of Resident 11's physicians order revealed an order dated October 17, 2025, for Enteral Feed Order one time a day for Feeding Continuous Tube Feeding: Product: Jevity 1.5 At 65 ML/ Hour via peg tube. Up at: 1600 Down when total volume of 1300MLs have been infused. Total Calories: 1950 kcal. Review of Resident 11's medication administration record (MAR) for October and November 2025 revealed Resident 11 received a total Jevity 1.5 volume on October 1- 1000ml; October 8 no amount recorded; October- 11, 13, 14 900ml; October 15-820ml; November 18-839ml and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy reviews, clinical records review and staff interviews, it was determined that the facility failed to develop physician orders regarding respiratory care for 1 of eight resident's reviewed (Resident 2).Findings include:Review of Resident 2's face sheet revealed medical diagnoses that include Nontraumatic Intracerebral Hemorrhage in Hemisphere Subcortical (spontaneous bleeding within brain tissue), Acute Respiratory Failure with Hypoxia (sudden inability of lungs to provide adequate oxygen to blood), and Tracheostomy Status, (surgical procedure that creates an opening in the neck to facilitate breathing when the usual airway is obstructed or compromised).Review of facility policy titled Tracheostomy Care, last revised January 2, 2026, revealed compliance guidelines noting the facility will provide necessary respiratory care and services, such as oxygen therapy, treatments, mechanical ventilation, tracheostomy care and/or suctioning. Review of Resident 2's physician orders failed to reveal orders for oxygen therapy including method of administration, volume to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-14 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, clinical records review and interview with staff, it was determined that the facility failed to ensure fluid restriction orders for dialysis residents were followed for one of one dialysis resident reviewed. (Residents 55). Finding include: A review of the facility's policy titled Fluid Restriction, dated 1/1/26, revealed the following guidelines for restricting fluids: The nurse in collaboration with the dietician will obtain and verify the physician's order for the fluid restriction and an order written to breakdown include the breakdown of the amount of fluid per 24 hours to be distributed between the food and nutrition department and the nursing department and will be recorded in the medical record. Review of Resident 55's diagnosis list includes End Stage Renal Failure (ESRD- failure of kidney function to remove toxins from blood), and dependence on renal Hemodialysis (A process of purifying the blood of a person whose kidneys are not working normally). Review of Resident physician's orders dated December 16,2025 revealed an order for daily Fluid…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-14 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observations, and staff interview it was determined the facility failed to label and store medications in accordance with currently accepted professional principles for 2 out of 3 medication carts reviewed. (1st and 2nd floor back hallway medications carts)Findings include:Review of facility policy (undated), titled: Medications with Shortened Expiration Dates revealed all eye drops must be dated upon opening and discarded 3 months after opening unless they have a shortened expiration date.Observation of the 2nd floor back hall med cart on January 13, 2026 at 9:45 a.m. revealed, Open Redness Reliever eye drops (saline eye drops) undated open Artificial Tears (saline eye drops) dated 8/26/2025 and open Artificial Tears dated 8/31/2025.A review of the 1st floor back hall medication cart on January 13, 2026 at 10:00 a.m. was observed to be unlocked and standing out in front of a resident's room at the end of the hall. When staff came out of the resident's room, they were asked who was responsible for the med cart. They replied that they were not the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-14 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview it was determined the facility failed to provide specialized speech therapy services as determined in their comprehensive care plan for 1 out of 1 resident reviewed. (Resident 29)Findings include:Review of Resident 29's diagnosis list revealed the resident was admitted to the facility on [DATE] with traumatic hemorrhage of right cerebrum with loss of consciousness (a type of stroke that causes bleeding in the skull), aphasia (difficulty speaking caused by damage to the brain) and dysphagia (difficulty swallowing that can be caused by a stroke) and feeding tube (a feeding tube placed in the stomach) that was placed during her stay in the hospital, and she is receiving 100% nutritional needs through her feeding tube.Review of Resident 29's care plan dated December 15, 2025 revealed an intervention of Skilled ST (speech therapy) services as ordered for strengthening and PO (by mouth) trials to improve oropharyngeal (swallowing) function and ability to tolerate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-14 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, observation and staff interview, it was determined the facility failed to maintain accurate and complete clinical records for one out of 8 residents reviewed. (Residents R31)Findings included:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-21 · tag F0910 — isolatedEnsure resident rooms meet each resident's needs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations and interviews with staff, it was determined that the facility failed to provide a safe environment for 1 of 3 residents reviewed (Resident 1).Observations made on November 21, 2025, of rooms on the Rehabilitation Unit revealed Resident 1's room had a window with broken glass pieces taped with duct tape. Further observations revealed broken pieces of glass were sitting between the glass panel and the screen.Observations made of Resident 1's room also revealed a dresser with two broken drawer fronts. The pieces were sitting inside of the drawers. Observations conducted with the Director of Nursing (DON) on November 21, 2025, at 1:07 p.m., when the above information was presented, the DON confirmed the glass and dresser drawers were broken. 28 Pa. Code 201.14 (a) 28 Pa. Code 201.18 (b)(1)(e)(1) (2.1)
- Potential for harm · D2024-11-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for one of twenty-two residents reviewed (Resident 28). Findings include: Review of facility's policy regarding medication administration, revealed that medications are administered as prescribed in accordance with good nursing principles and only by persons legally authorized to do so. Right resident, right drug, right dose, right route, and right time are applied for each medication being administered. Medications are administered in accordance with written orders of the prescriber. Review of Resident 28's quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated August 31,2024, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and had diagnoses that included Chronic Systolic (Congestive) Heart Failure (long-term condition that happens when your heart can't pump blood well…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 8 citations
- Potential for harm · D2024-11-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility's policy, clinical records review, and staff interview, it was determined that the facility failed to timely and appropriately address a significant weight change for one of 22 residents reviewed (Resident 93). Findings include: Review of the facility policy titled Weight Policy, dated August 29, 2023, revealed that all weights are to be documented in the electronic medical record. Weight variances will be reviewed by the dietician and the Interdisciplinary team (IDT). Confirmed re-weights will be documented in the electronic medical records. The dietitian will reassess the nutritional needs and intakes of any resident with a significant weight change. Interventions will be evaluated and documented. The resident's physician and responsible party will be notified of any significant weight changes. Review of Resident 93's clinical records revealed resident was receiving a continuous enteral feeding via gastrotomy tube (GT- tube inserted through the abdominal wall used to give drugs and liquid food to the patient) at 1560 ml., for total calories of 1872…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon clinical record review, it was determined that the facility failed to ensure that medication irregularities were acted upon by a physician for one of five residents reviewed (Resident 67). Findings include: Review of Resident 67's clinical record revealed Resident 67 was admitted to the facility on [DATE]. Review of Resident 67's clinical record revealed Resident 67 currently has a BIMS (Brief Interview of Mental Status) score of 5, indicating severely impaired cognition. Review of Resident 67's clinical record reveal medical diagnoses of Restlessness and Agitation, Unspecified Dementia (loss of memory, language and other thinking abilities that interfere with daily life) with Behavioral Disturbance, Cognitive Communication Deficit, Alzheimer's Disease, Unspecified Protein Calorie Malnutrition, and Nutritional Deficiency. Review of Resident 67's clinical records revealed a physician order dated May 25, 2024, for Mirtazapine oral tablet 7.5 mg. for appetite. Review of Resident 67's clinical records…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-14 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of job descriptions it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure proper infection prevention procedures were followed to protect residents from the spread of COVID-19 in the facility. Findings include: Review of the job description for the Nursing Home Administrator revealed the primary purpose of the job position is to direct day-to-day functions of the Facility in accordance with current federal, state, and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Review of the job description for the Director of Nursing revealed the purpose of the job position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guide[lines, and regulations that govern our Facility and as may be directed by the Administrator or the Medical Director to ensure that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-14 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interview it was determined the facility failed to provide a safe environment on one of two units. (2nd Floor) Findings Include: Observation on December 11, 2023 at 10:30 a.m. revealed the tub room which was currently being use for storage due to renovation and was storing buckets of paint revealed the door to the room which had a keypad was unsecured and able to be opened by the surveyor without inputting the keycode. Further observation on December 11, 2023 at 10:35 a.m. revealed an unmarked door at the end of the north hallway was able to be opened allowing access to a small room containing waterpipes and an air duct. Observations on December 12, 2023 at 12:30 p.m. revealed the doors to the dirty utility room, clean utility closet, and a linen closet all had numerical keypads. All three doors were able to be opened by the survey without inputting the keycode. Additional observations conducted on December 12, 2023 at 12:30 p.m. and December 14, 2023 at 10:46 a.m. revealed the unmarked door at the end of the north hallway to the small containing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, facility policy and procedure review, and staff and resident interview it was determined the facility failed to report an allegation of abuse to the state agency for one of 3 residents reviewed (Resident 19) Findings Include: Review of facility policy titled Abuse, Neglect, and Exploitation implemented November 1, 2022 revealed the facility will report all alleged violations to the state agency not later than 2 hours after the allegation is made. If the events that cause the allegation involve abuse or result in serious bodily injury. Interview with Resident 19 on December 12, 2023 at approximately 12:00 p.m. revealed there was an incident a few months ago where a nurse aide threw a magnifying glass at the resident when he/she became upset about the way the resident wanted to be changed. Review of Resident 19's progress notes revealed a nursing entry dated July 26, 2023 at 5:03 p.m. stating Resident called writer to [resident] room and stated that CNA (Certified Nursing Assistant) threw a magnified glass at [resident]'s face. Review of electronic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — the official record, unedited, may be distressing
Based on clinical record review, it was determined that the facility failed to ensure that a discharge summary was completed in a timely manner for one of three closed records reviewed (Resident 94). Findings include: Review of Resident 94's clinical record revealed the resident discharged home on October 23, 2023. Interview with the social worker Employee E8 on December 14, 2023, at 11:25 a.m. confirmed Resident 94's discharge home was a planned discharge. Review of Resident 94's clinical record revealed the resident's discharge summary was not completed by the physician until November 15, 2023. The above findings were confirmed with the Nursing Home Administrator on December 14, 2023, at approximately 12:15 p.m. 28 Pa Code 211.5 (f) Clinical records
- Potential for harm · D2023-12-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, observations, and interviews, it was determined that the facility failed to ensure proper assessments and treatments were in place for two of five residents reviewed for pressure ulcers (Residents 26 and 89). Findings include: Review of facility policy and procedure titled Pressure Ulcers dated August 29, 2023 revealed the effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Review of Resident 26's progress notes revealed a nursing entry on June 30, 2023 at 1:25 p.m. stating resident noted with DTI (deep tissue injury- injury to tissue due to prolonged exposure to pressure that is under a layer of intact skin) black color to left heel. Resident verbalizes no complaints of pain or discomfort to the area at this time heel boots was put on and treatment to the heel administered Further review of Resident 26's clinical record revealed there was no full assessment of the wound other what was described in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-14 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and clinical record review, it was determined that the facility failed to ensure complete and accurate clinical records for one of 22 residents reviewed (Resident 91). Findings include: Interview with Resident 91 on December 12, 2023, at 10:55 a.m. revealed the resident was admitted to the facility with a foley catheter (thin, flexible tube placed in the bladder through the urethra to drain urine) but it had recently been discontinued. Review of Resident 91's clinical record revealed a nursing progress note dated December 6, 2023, which stated that the resident's foley catheter had been discontinued. Further review of Resident 91's clinical record revealed nursing progress notes dated December 8, 9, 10, and 11, 2023, which stated: Has Foley catheter. Urinary device is patent and draining; free from complications. Catheter care provided. The inaccurate documentation regarding Resident 91's foley catheter was discussed and confirmed with the Nursing Home Administrator and Director of Nursing on December 14, 2023, at 1:35 p.m. 28 Pa. Code: 211.5 (f) Clinical records…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$49,590 in federal fines across 3 penalties. 1 Medicare payment denial on record.
- $10,256 — penalty dated 2024-01-22
- $6,480 — penalty dated 2023-12-26
- $32,854 — penalty dated 2023-12-14
- Medicare payment denial — starting 2024-01-18 for 5 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to PRESTIGE HEALTHCARE ADMINISTRATIVE SERVICES — 15 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 3.0 | ≈ chain avg |
| Staffing | 2 of 5 | 2.9 | -0.9 vs chain |
| Quality measures | 4 of 5 | 4.1 | ≈ chain avg |
The other 14 homes this chain runs (chain average 3.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PHWH HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 40% | since 10/01/2020 |
| KARMEL, JACOB | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 59% | since 10/01/2020 |
| TORNARI, CATHERINE | Individual | W-2 MANAGING EMPLOYEE | — | since 08/10/2017 |
CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.9M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in PA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395173. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.